The Meaning of Spirituality and Spiritual Well-Being among Thai Breast Cancer Patients: A Qualitative Study.

CONTEXT: Spirituality is the essence of a human being. Patients who have good spiritual well-being (SWB) will also have better quality of life. However, health-care providers usually under-assess this aspect due to lack of practical guideline. In Thailand, the validated survey came from a different cultural background and was heavily based on Buddhism approach. AIMS: The aim of the study is to assess the meaning of spirituality and SWB in Thai breast cancer patients in Southern Thailand where people have more diverse cultural and religious background. SETTINGS AND
DESIGN: Descriptive qualitative phenomenology design. SUBJECTS AND METHODS: In-depth interview with stratified purposive sampling method. The interviews took place in the oncology outpatient unit department and participants' home. Inclusion criteria were being diagnosed with breast cancer, age over 18 years old, able to communicate in Thai, has a Palliative Performance Scale more than 50, and was not diagnosed with any psychological disorder. STATISTICAL ANALYSIS USED: Descriptive statistic.
RESULTS: From October 2016 to February 2018, 16 women joined the study. Three themes emerged with five subthemes: (1) feeling life worthwhile, (2) sense of belonging in the community, and (3) feeling connected to the nature.
CONCLUSIONS: For Thai women, who have breast cancer, their spirituality focuses on family, mainly their children. They also have better SWB if they have good family relationship, social support, or feeling connected with nature or higher being in a religious or nonreligious way. Future survey design needs to be broader in a secular view and on another perspective rather than the religious approach.

INTRODUCTION

Spirituality is the essence of a human being: The meaning of life, feeling of connectedness to the transcendental phenomena such as the universe or god.[123] This connectedness may or may not be part of any religions.[45] It is also part of comprehensive palliative care, defined by the World Health Organization.[6] An individual's spiritual well-being (SWB) is a feeling of one's contentment that stems from their inner self and is directly related to their quality of life (QoL).[2]

Research has shown that patients who have good SWB will have better QoL, more satisfaction with their healthcare,[7] and acceptance of their disease.[12346891011] Terminal patients who have high SWB also reported fewer physical symptoms and a lower risk of depression as well.[16] Plus, patients with high SWB will have a greater eagerness to initiate their advance care planning and other unreported symptoms to doctors which will also increase their SWB afterward too.[9] However, health-care providers usually under-assess this aspect.[712] This was caused by a lack of awareness within the healthcare team, and also a lack of practical guidelines to assess patients’ SWB.[13]

In Thailand, research in SWB is still lacking. The validated SWB survey available came from a different cultural background namely from Western culture that may not be relevant in Thailand.[141516] Even though there was a validated survey created in 2014, the survey could only be used among Thai Buddhist adults with chronic illnesses.[17] Other works were also based on Buddhism that may not be applicable to those who do not feel religion as their spirituality.[1819] Thus, this study aims to assess the meaning of spirituality and SWB in Thai breast cancer patients in Southern Thailand where people have a more diverse cultural and religious background.

SUBJECTS AND METHODS

Participants

In-depth interviews with a stratified purposive sampling method. We selected participants who had been diagnosed with different stages of breast cancer and diverse sociocultural backgrounds. We also used investigator triangulation methods, data triangulation, and member checks to increase the rigor of our work.[20] The interviews took place in the oncology outpatient department and participants’ home. Inclusion criteria were: being diagnosed with breast cancer, age over 18 years old, able to communicate in Thai, has a Palliative Performance Scale (PPS) more than 50 and was not diagnosed with any psychological disorder. Exclusion criteria were: PPS ≤50, or too frail to continue in the study. Our palliative care nurse (KT) would recruit participants and send them into a private room where another researcher (TRP) conducted the interview. TRP performed all follow-up interviews and questionings from the out-patient department or at participants’ home as needed. The interviews focused on participants’ spirituality and their SWB using FICA spiritual assessment tool as the guide for the interview.[21] The tool emphasizes on four domains of spiritual assessment; faith (Do you have spiritual beliefs that help you cope with stress? What gives your life meaning?), importance (What importance does your faith or belief have in your life? Have your beliefs influenced you in how you handle stress?), community (Are you a part of a spiritual or religious community? Is there a group of people you really love or who are important to you?), and address in care (How would you like your health-care provider to use this information about your spirituality as they care for you?).

From October 2016 to February 2018, 16 women joined the study.

Theoretical framework

We used Fisher's four domains of spiritual health and well-being as our theoretical framework.[22] Fisher proposed that an individual's SWB is categorized into four domains – personal, communal, environmental, and transcendental. Moreover, their SWB is a combination of four domains synergized altogether, making a person whole. The personal domain is the domain where one intra-relates self to their purpose or meaning of life. The communal domain is related to interpersonal relationships with others whereas the environmental domain is one's sense of unity with the environment and the transcendental domain is the relationship to those beyond the human level; cosmic force, God, and ultimate concern.

All conversations were voice-recorded and transcribed verbatim. Any unclear transcription and interpretation were rechecked by member check method - the transcript of the interview was reread by the interviewees to check for the meaning and expression of their words and the team's interpretation. After that, all researchers would individually create codes. Any discrepancies would be discussed thoroughly in meetings before the final analysis.

RESULTS

Participants’ ages ranged from 38 to 68 years old with the mean age of 52.7 ± 8.9 years. The majority of were married (68.8%), Buddhist (75%), living with children and their children's spouse (37.5%), and received the primary level of education (56.2%). Twelve of them were diagnosed with breast cancer Stage I and II (37.5% each). About 56.2% of participants had a PPS of 90% [Table 1]. The interviews lasted 43–97 min.

Table 1

Participants characteristics

Characteristic	n
n	16 (100)
Age (years)
Mean±SD	52.7±8.9
Marital status
Single	2 (12.5)
Married	11 (68.8)
Widowed	3 (18.7)
Religions
Buddhist	12 (75)
Muslim	3 (18.7)
Christian	1 (6.3)
Living arrangement
Living with spouse	6 (37.5)
Living with children and their children’s spouse	4 (25)
Living alone	2 (12.5)
Living with other family members	4 (25)
Education level
Primary	9 (56.2)
Secondary	5 (31.3)
Tertiary	2 (12.5)
Breast cancer stage
I	6 (37.5)
II	6 (37.5)
III	3 (18.7)
IV	1 (6.3)
Duration after the diagnosis (months)
6-12	3 (18.7)
12-18	5 (31.3)
18-24	4 (25)
>24	4 (25)
PPS (%)
100	1 (6.3)
90	9 (56.2)
80	3 (18.7)
70	2 (12.5)
60	1 (6.3)

SD: Standard deviation, PPS: Palliative Performance Scale

PPS = Palliative Performance Scale.

Eight participants had their interview at home and four of them at the hospital. Four of them had their interviews at the hospital followed by an additional interview at home. Eleven of them finished the interview in one session whereas four of them needed the second follow-up. One participant needed a third follow-up [Table 2].

Table 2

Place and number of the interviews

Place	n (%)	Number of the interview session, n (%)
		1	2	3
Home	8 (50)	7 (87.5)	1 (12.5)	-
Hospital	4 (25)	4 (100)	-	-
Hospital then home	4 (25)	-	3 (75)	1 (25)
Total	16 (100)

For their SWB, 12 participants reported that they felt very “content” with their life. Four participants described their current situation as “somewhat ok.” As for the meaning of their spirituality, three themes emerged with five subthemes as shown in Table 3.

Table 3

Meaning of participant’s spirituality

Spirituality	Categories	Sub categories	Quotes
Feeling life worthwhile	Personal (5 out of 16)	Being independent (3)	“I could do chores, going to the market, temples, and drive a car so I feel totally fine. It (cancer) does not bother me
		Being at peace with self and others (2)	“It’s interesting how we could quarrel over trivial things with others. I forgive them all after I have this (cancer)”
	Family relationship (16 out of 16)	Children being independent (12)	“My kids are all married and have jobs. I have nothing to worry at all”
		Spousal/family support (4)	“He (husband) is always there with me. I couldn’t ask for more. (eyeing husband lovingly)”
Sense of belonging in the community	Social support (4 out of 16)	Normalisation (2)	“People said that I look totally normal. Do not have the “cancer” look (laugh)”
		Feeling loved and supported (2)	“They (friends) support me a lot and I feel really grateful to them”
Feeling connected to the nature	Religious (7 out of 16)	Karmic retribution (4)	“Karma. If you did good, you will receive good things in your life. So I’m trying to think and act in a good way”
	Nonreligious (3 out of 16)	Connected with god/higher being (1)	“It’s a test of faith and I’m embracing it. God does not cast this upon me without a good reason”
		Stronger faith (2)	“It’s part of life. We were born, grew up, got sick, and die. Who are we to go against that? I’m just going through that cycle”
		Being part of the nature (3)

Feeling life worthwhile

This theme, coincided with previous studies, showed that participants who felt that their life had been worthwhile would have higher SWB.[12345678910112324] On the individual level, participants who are still independent feel more content with their current situation. Furthermore, those who feel at peace with self and others also report having good SWB. They felt their life worthwhile if they are being at peace with themselves and others, for example, no unfinished businesses or unsolved conflicts with others. On the other hand, participants who have declining PPS and have decreased function in daily life still report of good level of SWB but to a lesser extent. “I’m happy and well. Only that it's a bit of a bother that it takes longer to climb stairs or when I tend the garden.”

The second subtheme about the family relationship was mentioned in all participants as one of the most important things in their life. In participants, who have children, they put emphasis on their children being independent. Interestingly, all would feel that their children are independent when they graduated from the university and have an income. This may be a part of the Thai context that most children are still dependent on their parents financially until they graduated or married. This theme shows participants’ supporting circle from their innermost circle to another one; their inner self and their family. The next theme demonstrates another supporting circle.

Sense of belonging in the community

Apart from themselves and family, their friends also have an impact on their SWB. Participants who have good SWB also have peers to help them get through their ordeal. Plus, if they were perceived as “normal” by the society, they also have good SWB. This phenomenon reflects the social construction about how women with breast cancer see themselves and how the society sees them. They may be socially stigmatized as a cancer victim needing help in what they do during the initial phase but it will gradually getting better once they regain their normality or get close to it.[252627]

Feeling connected with nature and higher being

This theme reflected participants’ feeling of connectedness to nature or the universe.[1234591011] From the religious point of view, they would describe this as having a stronger “faith.” Participants felt that they were tested on their faith and feel even more connected to their god more than ever. For Buddhist participants, they described this phenomenon as a part of karmic retribution, rationalizing that having cancer was the consequences of their actions in the past.

As for the nonreligious point of view, participants would relate their spirituality as being part of the nature. They viewed their life as one part of the cycle of life that would eventually fade away in time and having cancer was a part of this process. This could be seen as the transcendental domain in Fisher's framework of the spiritual domain as well.[22]

DISCUSSION

Spirituality is one of the key components of a human being and palliative care. It is one of the key elements that affect patient's QoL, physical, and psychological symptoms. Our work demonstrated a new vision of spirituality and SWB in Thai women who have breast cancer. The findings suggest that Thai women who have breast cancer viewed their spirituality on three levels; individual level, community, and transcendental level, coinciding with Fischer's spirituality framework.[22] Unlike previous works, this study shows a broader perspective to assess patient's spirituality in which religion, especially Buddhism, is a part of a larger holism of their SWB.

On the individual level, given that Thai is a collective culture where people put family above their individual needs, it shows on the first theme about the importance of family to these participants.[28] These women would feel their life worthwhile if their family life was well and would continue to feel so if they were certain that they would be fine even after they had gone. At a community level, there was an emphasis on a sense of normality, which is relatable with other works where women with cancer are struggling with the social demands of how they should behave and how they should be perceived; starting as a stigmatized cancer victim and eventually, a survivor that still fits in the society.[27] For the last theme, participants feel more connected to the nature in a transcendental level in both religious and nonreligious ways. For the religious participants, all of them reported being more religious and more vigorous towards their religious doctrine and ceremony, seeing cancer as a trigger that strengthened their faith. For the nonreligious participants, they focused on feeling connected with the nature by having cancer as a trigger of reflection, where things eventually fade away as well. These findings should be seen as preliminary results that can inform a new survey that will assess patient's SWB in a more objective sense so that it will be more practical for other healthcare providers to use.

Our work is the first study that explores the meaning of spirituality in Thai women with breast cancer, and their meaning differed from previous works that focus on other diseases. We also enhance the rigor using multiple triangulation approaches. The majority of the interviews were also conducted at participants’ homes where they would feel more at ease to talk about their inner self's meaning of spirituality.

Limitations

We have several limitations. First, the analysis focused on participants who were in the early stage of cancer. Their spirituality and SWB may differ from those who have deteriorated health.[11229] Since one of the key themes is being independent and declining health would mean that their SWB may change over time and could decline with the trajectory of the disease or their changed social function.[210]

A regular assessment on patient's SWB is recommended. However, health-care providers may not be too proactive about this as since most patients prefer to form a better doctor–patient relationship first to feel safe enough to initiate discussion about their innermost concerns.[1229] Second, the majority of our participants are married females thus their spirituality and SWB mainly focus on their children and family relationship which is relatable to Thailand's culture that women who have family tend to put their family above their individual needs.[1630] Third, even though we tried to recruit participants with several backgrounds, the majority were Buddhist housewives that felt content with their life. They felt that they had a healthy family relationship and had no unfinished businesses. Thus, data from other subgroups, for example, participants who have young children, single females, males, those who have family conflict, or those who have spiritual distress may yield additional data or different concept of spirituality.

CONCLUSIONS

For Thai women, who have breast cancer, their spirituality focuses on family, mainly their children. They also have better SWB if they have good family relationships, social support, or feeling connected with nature in a religious or nonreligious way. Future work needs to explore these issues to improve and maintain their SWB as their disease progresses. Future survey design also needs to be broader in a secular view and on another perspective rather than a religious approach.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.